Ethical Responsibilities

in Nursing: and Issues

Research Findings

VIRGINIA R. CASSIDY, EDD, RN*

Discussions in the literature assert that nurses are becoming increasingly cognizant of their ethical responsibilities, but that they are often ill prepared to participate in ethical decision making. A review of selected research literature from 1970 to 1987 was undertaken to validate these assertions. A total of 12 studies related to ethical responsibilities was identified in the review; all studies were published between 1980 and 1987. The majority of studies were at the descriptive and exploratory levels and employed Kohlberg’s cognitive theory of moral development as their conceptual framework. Significant findings related to educational level and ethical responsibilities were consistent across studies. Findings related to age and clinical experience were mixed; the effects of economic level, religion-religiosity, ethnicity, and other varlables on ethical responsibilities were not significant. Issues raised in the light of the existing research include the use of Kohlberg’s theory as a conceptual orientation in nursing groups and limited data on the reliability and validity of instruments used In measuring ethical constructs. Recommendations for future research on ethical responsibilities include the validation of Kohlberg’s theory for nursing investigations, exploration of other frameworks for developing a multidimensional view of ethical responsibilities, and the use of qualitative research designs. (Index words: Ethical decision making; Ethical responsibilities; Professional ethics) J Prof Nurs 7:772778, 7997. Copyright 0 7997 by W.B. Saunders Company

transformed tech”

A recent

health

care delivery

regulations

regarding

the dependence

on this technology, the allocation

of and

of health

In the last 2 decades

focused on the changing als in addressing delivery. example

creation

care professional

of ethics

complex

approaches

of their practice,

in decision

is addressed

in a growing

making

are made on a recurring

creasingly

cognizant

providing

care (Davis, is that

prepared

(Aroskar,

basis in this in-

of their ethical responsibilities

in

nurses

1981;

Murphy,

are, however,

to participate inability

of knowledge

1984).

often

times

in the decision-making ethical

dilemmas

to recognize

to validate

of ethical

review of selected The following

a dilemma,

these assertions

research

discussion

the current

responsibilities literature

describes

the major findings

to a new and intense awareness of the ethical aspects of health care delivery.

offers some recommendations for additional in the area of ethical responsibilities.

in diagnostic

and treatment

and ad-

modalities

have

*Associate Professor, Northern Illinois University School of Nursing, DeKalb, IL. Funded by the Summer Scholarship Support Program, Northern Illinois University School of Nursing, DeKalb, IL. Address correspondence and reprint requests to Dr Cassidy: Northern Illinois University School of Nursing, DeKalb, IL 60115. Copyright 0 199 1 by W.B. Saunders Company 8755-7223/91/0702-0013$03.00/O

112

a

was conducted.

raises issues inherent

and implementation

in the

level of un-

tualization

nology in health care has become widespread

or lack

in nursing,

care resources are major factors that have contributed

vances

pro-

processes

from this review,

Since the 197Os, the use of tech-

ill-

1985).

and to determine

derstanding

The

due to role

about ethical decision-making

1982; Fry,

In an attempt

issues,

literature.

are becoming

cesses used to address constraints,

ethical

body of nursing

The first is that nurses

the

and to be active

about

literature.

second

and identifying

to be able to recognize

participants

Two assertions

of

in addressing

in the area of ethics.

The need for nurses ethical dimensions

policies,

has

the value

and debate

issues, formulating

educational

making

exemplify

discussion

is one

the role of health

decision

committees

interdisciplinary

of health care

committees

about

in ethical

These

has

role of health care profession-

of how perspectives

changed.

as a “high

attention

the ethical dimensions

The

literature

DVANCES in technology,

care into what is now perceived

endeavor.

in the concep-

of the research,

and

research

Approach Seven journals*

that are dedicated

in whole or in

part to the publication of nursing research were selected as the sources for this review because they serve

*Advances in Nursing Science, Image, International Jourmal of Nursing Studies, Journal of Nursing Education, Nursing Research, Reseat& in Nursing and Health, Western Jourual of Nursing Research

Journalof ProfesssionalAlming,

Vol 7, No 2 (March-April),

1991:

pp

112-l 18

113

RESEARCH ON ETHICAL RESPONSISILITIES

as the major outlets findings

for the dissemination

for the profession.

they were (1) published scientifically

executed

tered nurses,

enrolled

of higher with

were defined

processes

evaluating

and/or

ethical

situations

ethical action,

Swider, McElmurry, in these

studies

medical

Steiner-Freud,

Ethical

sociate or bachelor’s education

or

a moral decision.

such as moral behav-

moral judgment,

ethical choice,

making,

rights were included

and attitudes in the analysis.

majors

(Davis,

1981;

Numerous

in the analysis was identified

None of the studies were published

during

Five of the studies

were published

seven were published

198lb,

1985;

1987; Gaul,

in 1985 or

ical responsibilities.

making

the relationships

between

and other variables

& Parsons, Pinch,

1987;

1985).

(Crisham,

Ketefian,

Two

&

1981a,

studies

various

1987) were quasi-experimental

Frisch, hall,

cognitive

(Crisham,

orientation

an ethical

1987;

& Parsons,

Ketefian,

1985). Other

198Ib;

theoretical

1987;

of responsibility

the Code for Norm

198Ib,

1985), and concepts related to professionalism

construct

(Felton

(Gaul,

1985). Three studies (Davis, & Steiner-Freud,

& Yarling,

& Parsons,

1987;

Ketefian,

dilemma.

definition

fined it specifically Eighty-seven

students

1987; Frisch,

25 per cent

incident

1987; Gaul,

McEl-

198 1; Felton & Parsons, 1987; Kurtzman,

dilemma”

(ie, abortion,

death,

of the subjects

where they faced an ethical were placed treatment,

Swider,

into

prolonging

among

with a broad subjects

de-

and dying). described that

an these

included

life, and the allo-

others.

& Yarling made by student

case study employed

40 per

dilemma;

categories

McElmurry,

that the decisions

TABLE 1.

(1985) reported groups about the

in the research were classified

as

Variables Measured by the DIT

Author

Variable

DIT Scores

Crisham (1981)

Moral judgment, familiarity with dilemmas Ethical-moral reasoning, dilemma resolution Level of principled thinking Moral reasoningjudgment Moral reasoning Level of moral reasoning

P and D scores F score

Felton & Parsons (1987)

1985) did not report a theoretical

(Crisham,

Approximately

and the remaining

per cent

1981; Kurtt-

1985; Swider,

orientation in their studies. In the majority of studies students served as the research subjects; bachelor’s degree nursing majors comprised a portion of the sample in all the studies involving

in Table 2.

Mun-

1987),

murry,

in

measures

perspec-

bution

Block,

A

by the DIT

1. Other

are summarized

cent defined the term “ethical conceptual

withholding

for the majority

1981; Felton

1987; Gaul, 1980; Pinch,

(Ketefian,

measured in Table

Davis ( 198 1) found that approximately

in their

tives for the studies were derived from Heider’s attri-

man,

is provided

of ethical responsibility

dilemmas

theory of moral development

the conceptual

of studies

by Rest (1979) was used

aspects of moral development.

cation of resources,

Kohlberg’s

eth-

In six of the studies the Defining

of the variables

(Frisch,

design. provided

were used to measure

Issues Test (DIT) developed

defined

Block, & Steiner-

1980; Swider, McElmurry,

1985) or explored Felton

nurses as the research

in 1980 or 1981

198 1; Kurtzman,

1985; Munhall,

1981;

re-

the 1970s.

of the studies were either descriptive

in nature (Davis,

ethical decision

studies 1985)

of the sample in her study did not define or incorrectly

1987. The majority

Yarling,

on practicing

Four

1981b,

in the review.

and the remaining

Freud,

for

&

nurses with as-

1981).

198la,

instruments

these studies A total of 12 studies that met the requirements

(Pinch,

Block,

subjects.

summary

Overview of Studies

program

or master’s degrees and graduate (Crisham,

Ketefian,

ported exclusively

students (Munhall,

(Kurtzman,

1985); and practicing

and af-

assessing,

degree

of a nursing

students

1985;

1985). Other groups

master’s

1987); faculty members

1980); recent graduates 1985);

1980; Pinch,

& Yarling,

included

(Felton & Parsons,

to measure

inclusion

1985; Munhall,

responsibilities.

variabfes

ethical decision

towards patients’

& Steiner-Freud,

as the cognitive

that necessitate

ior, moral reasoning,

sub-

programs

of the study

used in recognizing,

that included

if

were regis-

and (4) at least one variable

responsibilities

Studies

(3) included

in nursing

learning

was concerned fective

were selected

1970 and 1987, (2)

and reported,

jects who were students in institutions

Studies

between

of research

Block,

Frisch (1987) Ketefian (1981a) Ketefian (1981b) Munhall (1980)

D score DR score

I score, stage score P score P score D score

114

VIRGINIA

TABLE 2.

Other Measures of Ethical Responsibility

Author

correlations subscales,

Variable

Crisham (1981)

Instrument

Responses to real life, nursing dilemmas Nurses’ understanding of the concept of ethical dilemma Content of ethical dilemmas that confront nurses

Davis (1981)

Felton & Parsons (1987)

Gaul (1987) Ketefian (1981b)

Ketefian (1985) Kurtzman, Block, & Steiner-Freud (1985) Pinch (1985)

Swider, McElmurry, & Yarling (1985)

Commission, foreseeability, intentionality, and justification levels of responsibility in relation to ethical-moral dilemmas Ethical choice and ethical action Idealistic and realistic moral behavior Realistic moral behavior Attitudes towards the rights of hospitalized patients Decision making in ethical dilemmas Priorities in the decisions depicting an ethical dilemma

NDT (Crisham)

between

In evaluating sponsibilities consistent. diploma

JAND (Ketefian)

dilemmas

than bachelor’s degree nurses. that

ability

explain a significant

variance

(32.89

per cent) in DIT-P

educational

also found significant Idealist

differences prepared

between

the two groups on JAND scores were not significant.

ferences

by educational

centered

JAND (Ketefian) Questionnaire (researcher developed) Situations (researcher developed) Case study (researcher developed)

by Crisham Crisham

made

In analyzing

by various

cent),

the categories

demographic

of the

Ketefian

(1981)

differences

served on DIT-DR

tech-

nurses; differences Realistic

Behavior

Significance

and

& Parsons difference

and NDT

by educational

dif-

on DIT-D

Felton

also found a significant

level on the DIT-P

by

scores. No

level were ob-

or AR scores in the Felton

Kurtzman,

Block,

and

Steiner-Freud

ported that scores on attitudes were high

among

and

and fourth-year that freshmen

physician-

data,

decisions of decisions

bureaucracy-

and medical

differences

nursing

students.

their first choice in decision concluded

first-

advocacy approach significantly

and graduate

as less

nurses.

that the average level of

(DIT scores) for bachelor’s degree stu-

dents was at the conventional

level and that the av-

erage level for faculty was at the principled differences

differences

between

on DIT-D

on DIT-D

scores.

faculty

The effects of experimental on ethical

student

only between

making

often than did senior students

re-

rights

Pinch (1985) found

selected a patient

Munhall(l980)

(1985)

toward patient’s

all nursing

groups and significant

moral reasoning

(19 per cent), and patient-centered

(9 per cent).

critical

scores and

level were found

were found among the student per

scores.

on DIT-P

subscale

significant (60

and

proportion

Parsons’ study.

Abbreviations: NDT, Nursing Dilemma Test; AR, Attribution of Responsibility; JAND, Judgments About Nursing Decisions.

bureaucracy-centered

level

of ethKetefian

Behavior subscale scores between

nically and professionally

significant

by subjects;

definitions

found

educational

differences

were described

nurses gave fewer general

re-

was generally

Davis (198 1) found significant

thinking

(1987).

Behavior.

on ethical

across studies

(1981a)

JAND

the JAND

and Realistic

the effect of education

ical dilemmas

scores JAND (Ketefian)

scores and

Behavior

the finding

in how ethical Open-ended questionnaire (researcher developed) Open-ended questionnaire (researcher developed) AR (Felton & Parsons)

DIT-P

Idealistic

R. CASSIDY

responsibility

level. No

or DIT stage scores

groups,

but significant

and students educational

were generally

were found approaches not signifi-

centered decisions were selected at least 55 per cent of the time and patient-centered decisions were made only 5 per cent to 9 per cent of the time. Two authors (Crisham, 1981; Ketefian, 198Ib) looked at the relationships between components of

cant. Gaul (1987) observed no significant differences between experimental and control groups on JAND Idealistic or Realistic Behavior subscale scores. Frisch (1987) reported no significant differences between groups on DIT-P scores. Significant changes from

ethical responsibilities by comparing scores on the DIT with scores on instruments that they had developed. Crisham reported significant low correlations between scores on DIT-P, DIT-D, and the NDT. Similarly, Ketefian ( 198 lb) reported significant low

pretest to posttest were found in DIT stage scores for the experimental group, but stages of moral development could not be calculated for more than 50 per cent of the subjects. The findings related to age and ethical responsibil-

RESEARCH

115

ON ETHICAL RESPONSIBILITIES

ities were less consistent. age were found (Crisham,

No significant

differences

on scores of ethical

198 1; Ketefian,

198 la,

by

responsibilities

responsibilities

1980) or the types of dilemmas

reported

by subjects

Ketefian

(1985) did

report significant

differences

istic and Realistic

Behavior

by age on JAND subscale

study.

Davis (198 1) also reported

icantly

related

stitution

families,

scores in a later

that age was signif-

to the frequency

tered with patients,

of dilemmas physicians,

the effects of years of clinical responsibilities,

Munhall

found

(1980)

Crisham

no differences

and DIT stages scores, respectively; no significant

differences nificant

differences

on JAND

The effects of economic Munhall,

1980),

(Pinch,

reported

ethical matters

and the difficulty

and concepts.

the latter,

may well explain

were identified.

(Davis,

sig-

1980), re1981a;

1980;

1985; Swider,

nificant.

Ketefian

Ketefian,

analysis,

also studied

subscale

find-

than

Using

professional

mi-

descriptive priate.

of studies

or exploratory

level.

Given

were at a the limited

of research in this area this finding Only one study,

dilemmas

that 1981).

nurses

then

however, actuahy

explored encounter

Because this study

198 1, it should should

in this review

be replicated

be proposed

in practice

was published

and additional

to identify

dilemmas

is approthe ethical

on nurses

in

studies

the impact

of

and their prac-

Despiteheightenedawareness . , . littleresearch relatedto the ethicalresponsibilities of nurses

in JAND

was also explained

Realistic

Realistic

and by professiona

signif-

for 3 per cent of proportion

of the

subscale

scores

Behavior

by professional

nor-

Behavior subscale

A significant

role conception

role discrepancy

and bureaucratic

they only accounted

variance.

be-

regression

scores were statistically

JAND

scores; however,

bureaucratic

and

role conceptions

force stepwise

normative

mative role conception icant in explaining

variance

the relationships

and bureaucratic

behavior.

the explained

is still problematic

has been published.

(1985)

tween professional and moral

that

later in this discussion.

The majority

nori ty nurses. Ketefian

ethical

particularly

&

were not sig-

only one significant

Behavior

factors,

in

tice .

with Caucasian nurses scoring

on the Idealistic

interest

the few publications

Measurement

these “real-life”

demographic McElmurry,

1985) on ethical responsibility reported

recent

of measuring

These

of

in nursing”

Research Design

(Davis,

Ketefian,

Yarling,

ing related to ethnicity

it to the relatively

principles

a “paucity

inquiry

and attributed

amount

Behavior sub-

198 lb), and other nonspecified

characteristics

Realistic

experience.

1980;

ethnicity

( 198 lb)

did find significant

level (Munhall,

(Davis,

144) described

on the topic of ethical

(198 1) and

on JAND

Idealistic

scale scores by years of clinical ligion-religiosity

p.

re-

on DIT scores

on NDT scores and Ketefian

differences

(1985,

in the nursing

1980 and 1987.

experi-

Ketefian

Behavior subscale scores. Crisham

higher

and the in-

between

will be addressed

ences on ethical

198 la,

encoun-

of employment.

In evaluating

found

Ideal-

Gortner research

less than two studies on ethical

per year appeared

search literature

198 lb; Munhall,

(Davis,

198 1) in several studies.

appeared sporadically;

role conception

scores (11.4

role discrepancy

and

Two studies (Frisch, 1987; Gaul, 1987) were quasi-experimental in their design. It seems premature to propose additional present.

Clearly,

effects of cognitive, ables on ethical terventions

studies

additional affective,

responsibilities

to impact

at this level for the

studies

that evaluate

and experimental are needed

on these responsibilities

the vari-

before incan be

determined.

per cent),

and bureaucratic

Theoretical Orientation

scores ( 12.5 per cent). In the majority

Issues Despite heightened awareness about the ethical dimensions of practice and concerns about the ability of nurses to participate in ethical decision making, little research related to the ethical responsibilities of nurses has been published. The studies that were published

Kohlberg’s

of studies

cognitive

theory

included of moral

in this review, development

was used as the framework for the investigations. While this theory of moral development is widely discussed in the literature, the basis of its formulation may present problems that are significant to nursing. Kohlberg based his theoretical assumptions on data collected from only male subjects; because nurses are

VIRGINIA

116

predominantly

female,

the constructs

may not be valid in studying The assumption moral

1989).

1988) suggests

nursing

has recently

been

moral

in

development

(1982,

in women

differs from that of men and that the basic elements moral

judgment

depending

ligan postulates

but negates

women’s moral development; inent among

of

mas have recently second

Gil-

reviewed,

the care perspective

of Kohlseen in

reflective

of

thus, women are prom-

those who are found to be “deficient”

of Kohlberg’s

in

most

are limited.

widely

testing.

studies

positive

by Gilligan stein,

merous questions tions

and others

(1982)

1976; Kurtines

dence has been presented moral development (Kurtines subjects

& Greif,

theory

of other assump-

invariant

is not supported 1979). Further,

that nature

instruments

based

on Kohlberg’s

and inconsistent

theory

however, ethical

is a

responsi-

refinement

of these exist-

is clearly

warranted.

The measure-

in developing

(Ta-

a multidimensional

components

of nursing

and facili-

of the interrelationships

as moral development,

ior, and moral reasoning. addressed

and The

further

understanding

such components

Measurement

among

moral behavissues must be

as one of the first steps in the research pro-

gram development

the

in nursing

ethics.

to place using

has been

in several studies

Findings

of

by research data the ability

at specific stages of moral development

problematic

only,

on them.

Some evi-

in the literature

of the hierarchical,

studies

were reported

first step in understanding in nursing:

in

used to measure ethical

of these new instruments,

ble 2) is needed

1986; Hol-

of this theory.

of this caution

data from this subscale.

instruments data

for use in

ment of various aspects of ethical responsibilities

1979) has raised nu-

about the validity

in the development

assumption

(Bloom,

& Greif,

reported

moral behavior

the JAND

were used in single

ing instruments

tating of Kohlberg’s

and validity 1989)

idealistic

be mindful

to interpret

view of the ethical criticism

in the studies

1985,

selecting

should

if any,

development

was the

and should not be used for hypothesis

responsibility

further

(1982,

dilem-

The JAND

of its reliability

Investigators

limited,

of

is questionable.

used instrument

Ketefian

lacks reliability

bilities

&

the validity

to measure nursing

that the subscale to measure

future

Coder,

and given the crit-

above,

been developed.

The remaining

A major concern about the research in ethical responsibilities . . . is the reliability and validity of the instruments used in measuring this variable.

groups

but evidence

their attempts

moral development.

In addition,

Cooper,

theory,

A variety of instruments

ways

berg’s theory reflects the moral development males,

(Rest,

the DIT with nursing

in different

that the justice perspective

validity

1974). Because the DIT was based upon the

assumptions

is conceptualized.

can be organized

on how a situation

and

icisms of the theory discussed

challenged

The work of Carol Gilligan that

reliability Masanny,

groups.

that there are no sex differences

development

(Cooper,

of this theory

R. CASSIDY

(Kur-

tines & Greif, 1979). Additional evaluation of the validity of Kohlberg’s theory and its appropriateness for use in female populations is needed as research into ethical responsibilities in nursing continues.

Given

the conceptual

dressed above, the findings

A major concern about the research in ethical responsibilities that has been included in this review is the reliability and validity of the instruments used in measuring the various aspects of this variable. One half of the studies employed the DIT developed by Rest (1979); this instrument has been widely used in a variety of populations and does have documented

issues ad-

of all the studies

in the review should be viewed as tentative. surement

of moral development

among

included The mea-

nurses

based

on Kohlberg’s conceptualization may have underestimated the level of moral development among subjects because of the sex bias described

by Gilligan

(1982).

In addition, the inability to “stage” more than 50 per cent of subjects in Frisch’s (1984) study highlights one problem

Measurement

and measurement

with the use of an instrument

based on

Kohlberg’s theory. The findings of these studies do provide some support for the assertions in the nursing literature related to ethical responsibilities in nursing. Davis (1981) found that nurses do confront ethical dilemmas in their practice and the high scores concerning patients’ rights reported by Kurtzman, Block, and SteinerFreud (1985) suggest that nurses are cognizant of their

ethical

responsibilities.

Davis,

however,

also

RESEARCH ON ETHICAL RESPONSIBILITIES

found

that

nurses

117

have difficulty

in using

guage of ethics to define these dilemmas, account

for the perception

recognize

dilemmas

(1985) suggest

and Yarling

that perceived

a factor in understanding filling

their ethical

in which

ethical

impediment making

which may

that nurses are unable

in their practice.

Swider, McElmurry,

the lan-

The findings

role constraints

responsibilities;

decision

making

program

in ful-

students

responsibilities

subjects

decision-

related

instruction

in nursing

of

(Fry,

(Killeen,

opment.

1989) suggest

a

the need for ethics content

in pro-

“prompted

fessional curricula,

it is unrealistic

ethical matters. The content only serve as an introduction and must be expanded tinuing

education

The findings perceptions

to assume that such fully in all

included in curricula can to ethical responsibilities

through

self-directed

and con-

of studies

differentiating

responsibilities

nurses

level suggest that factors other than, or in addition exposure to specific ethics content

student

attributed matters

groups

to relatively among

that previous

ters can facilitate (Cassells

and concern.”

This

with ethical mat-

decision-making

1989).

with ethical

It has been suggested processes

Explorations

of ethical

as they relate to previous

experience

in nurses

moral

devel(1985,

Kohlberg’s

theory,

and

actions

compassion,

recommendation

care,

addresses

di-

rectly the concerns

expressed

by Gilligan

the care orientation

perceived

to reflect the moral de-

velopment

The exploration filling ranted.

ethical

of other theoretical the dynamics

responsibilities

and care is a major however,

orientations involved

in nursing

The work of Gilligan

Caution,

related

to

in women.

is also war-

has intuitive

sex

appeal

of nurses are women

component

of nursing

is suggested

in assuming

ligan’s theory (Cooper,

to

in ful-

(1982) in describing

because the majority

be

re-

If it is

in understanding

benevolence,

for nursing

experience

in dealing

ethical

& Redman,

responsibilities

little

experience

by direct

may account for the

could

as a con-

the ethical

judgments

in moral development

are perdifferences

theory

by Wallwork

of abandoning

to include

in-

for par-

be evaluated.

differences

in several studies

these subjects.

must

to,

differences in how ethical responsibilities ceived. In addition, the lack of significant between

on

by educational

needed

in understanding

more fully understand

activities.

of ethical

use of Kohlberg’s

p. 97) that instead

can

making.

It has been suggested

few would dispute

nurses to participate

the processes

the factors that enhance

it be expanded

can prepare

responsistudies

aspects of moral development

While

of

experimental

it can provide direction

and exploring

as

they can

of ethical

in designing

in nursing

the cognitive in

continue;

and exploratory

decision

orientation

at present.

content

on these matters

ceptual

appropriate,

to ethics

direction

The continued

about the extent

related

to the fulfillment

in ethical

sponsibilities

should

and validated

research and the exploration

to enhance

ticipation

1989), and approaches

ethics in nursing

terventions

of a research

the various aspects of eth-

are refined

These descriptive

pro-

curricula

content

(Cassells & Redman,

for teaching

in

studies with

decision-making

in the literature

the appropriate

lack of consensus

factors related

The

The development

in nursing

these instruments

bilities.

treatment

to the preparation

in ethical

cesses. Discussions

curricula

differences

between

in two experimental

raises issues

1986),

ical responsibilities be used in replication

occurs may be an

the lack of significant

nurses participating of ethics

to measure

then provide

scores on ethical and control

in ethical responsibilities.

of instruments

processes.

In addition,

serve as a foundation

research can, however,

of

may be

in ethical

existing

for future research and the development

the environment

to full participation

in the literature.

to

(1985) and Ketefian

how nurses respond

tion of the few studies published

practice. that Gil-

1989, p. 15) “provides

a suf-

ficient paradigm for the nurse in moral deliberation”; rather, “an ethic of care should be understood as a necessary

but

standing

ethical

(1988) suggests can provide

not

sufficient

framework”

responsibilities. that inquiries

an additional

in under-

Further, based on virtue

perspective

Brody ethics

on ethical

be-

with ethical matters, rather than nursing experience in general, may be an appropriate avenue to pursue in

havior by focusing on the moral actions or outcomes.

future

The emphasis on quantitative approaches for exploring ethical responsibilities in nursing should also be re-examined. In the majority of studies reviewed,

investigations.

Implications for Future Research Ketefian (1989) believes that the existing research on ethical responsibilities is neither cumulative nor built on previous research in any direct manner. This observation reflects the relatively recent interest in investigations in the area and the concurrent publica-

agent

rather

than

hypothetical dilemmas were used as the basis for data collection; these data, for the most part, were responses to predetermined, closed-ended questions about the dilemmas. The use of hypothetical dilemmas raises issues about familiarity with dilemmas,

VIRGINIA

118

which has been suggested the consideration

of ethical

attempts

to quantify

relatively

complex

as an important dilemmas.

relatively

aspect in

responses

of qualitative

portunity

In addition,

simple

vantages

approach

for nurses to identify

to

ical dilemmas

(2) an open-ended

that they actually

situations

raises measurement

is-

It may also be appropriate

to begin qualitative

ex-

topic; and (3) the possibility tual orientation

that would better represent

sues. plorations

responsibilities.

Qualitative

re-

search could have several advantages

in exploring

this

undefined,

exploration

of ethical complex

area of investigation.

Some ad-

sibilities

include:

R. CASSIDY

(1) the op-

and describe

the eth-

encounter

every day;

of ethical

dilemmas

the complex

nature of the

of identifying

for the investigation

a concep-

of ethical respon-

that may be more appropriate

than existing

orientations.

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